The Power of Modifier 25 in Urgent Care: Billing Procedures and E/M on the Same Visit

Are you confident that your urgent care practice is billing correctly when a patient receives both an evaluation and a procedure on the same day?

Do you know exactly when Modifier 25 should be applied to reflect a significant, separately identifiable E/M service? How can clear documentation, precise coding, and compliance with payer rules ensure maximum healthcare reimbursement?

This blog will help you master Modifier 25, which is essential for urgent care providers seeking to optimize revenue, maintain accurate claims, and demonstrate the full value of their clinical services.

Billing Procedures for Using Modifier 25 in Urgent Care

There are essential steps providers must follow to correctly bill a standalone E/M service along with a procedure during the same visit. It describes the need to show genuine medical necessity, document distinct clinical work and assign accurate codes that reflect both services. It also emphasizes reviewing payer rules, ensuring proper linkage of diagnoses and maintaining clear justification for the additional evaluation. These practices help support clean claim submission, reduce denial risks, and maintain strong compliance across urgent care billing operations.

• Confirm Medical Necessity for a Separate E/M

Medical necessity is established by assessing whether the patient's condition requires evaluation beyond the standard care included with the procedure. Therefore the provider must review symptoms, assess concerns, or make additional decisions that are not part of the procedure itself. This added work demonstrates that the E/M contributed meaningful value to the visit. When the documentation clearly supports this extra assessment, the claim becomes stronger and reduces the risk of billing challenges or payer disputes.

• Check the Procedure’s Global Period

Understanding the procedure’s global period helps clarify whether the E/M can be billed on the same day. As most urgent care procedures fall under a zero-day global period, only routine pre- and post-procedure tasks are included. Consequently, any extra evaluation requiring clinical judgment qualifies as distinct work. Thereby, recognizing this distinction ensures the E/M is not unnecessarily bundled which allows providers to bill both services when proper documentation supports the added effort.

• Verify that the E/M is “Significant and Separate”

A significant and separate E/M encounter exists when the provider performs an evaluation that clearly goes beyond what is typically required for the procedure. In many cases, this may involve additional medical decision-making, a broader examination, or addressing unrelated concerns. This distinction shows that the patient required more than procedural care alone. When the documentation reflects this added complexity, modifier 25 appropriately signals that the E/M stands on its own and justifies separate billing.

• Document E/M and Procedure in Separate Sections

Keeping the E/M note and the procedure description in distinct sections helps reviewers understand that two different services occurred during the visit. The E/M portion should describe symptoms, findings and clinical reasoning whereas the procedure note should explain the technique and immediate outcome. As a result, payers can easily follow the structure of the encounter. Therefore, clear separation strengthens the claim by highlighting the independent nature of the E/M service supported by modifier 25.

• Choose the Correct E/M Level Using MDM

Selecting the appropriate E/M level depends on evaluating the complexity of the medical decision-making rather than the procedure performed. In fact, the level should accurately reflect the number of issues addressed, the depth of assessment, and the risks considered. This alignment ensures the claim remains consistent with the documented work. Therefore, the billing remains reliable and accurately reflects the clinical interaction when the E/M level matches the recorded MDM.

• Apply CPT Codes and Add Modifier 25 to the E/M Only

Assigning CPT codes requires choosing the most accurate options for both the E/M and the procedure. In fact, modifier 25 must be attached solely to the E/M code to show that it was delivered independently of the procedure. Such placement prevents bundling errors and clarifies the billing intent. Also, the claim reflects the complete range of services provided when codes and modifiers are applied correctly to make it easier for payers to process without confusion.

• Link ICD-10 Codes Correctly for Both Services

Accurate ICD-10 linking ensures each service connects to the appropriate diagnosis. The E/M typically relates to the primary reason for the visit while the procedure may correspond to a related or secondary condition. Such structure assists payers understand the medical reasoning behind every service. As a result the claim becomes more logical and supports a smoother reimbursement process without unnecessary denials when the diagnoses align well with the documented work.

• Review Payer Rules and NCCI Edits

It is crucial to check payer guidelines and NCCI edits as it ensures that the E/M and procedure combination meets current billing standards. In fact some payers require additional justification or apply stricter modifier 25 rules to make it essential to review these policies beforehand. This preparation helps prevent denials and supports compliance with the latest regulations. Therefore the claim is processed more efficiently and with fewer interruptions when the billing aligns with payer expectations.

• Submit the Claim with Complete Documentation

Submitting the claim requires ensuring that all supporting documentation is clear, organized, and consistent with the coded services. In fact, well-detailed notes help payers recognize the necessity of both the E/M and the procedure. This level of clarity demonstrates transparency and supports the claim's validity. As a result payer reviews are smoother when the medical record aligns with the coding choices, reducing the risk of delays or additional information requests.

• Monitor Denials and Improve Compliance

Tracking denial trends offers valuable insights into potential documentation or coding issues. Identifying recurring patterns allows the team to strengthen workflows, refine templates, and improve provider training. Each denial becomes an opportunity to enhance accuracy and reduce future errors. When these improvements are applied consistently, compliance strengthens, billing reliability increases, and modifier 25 usage remains appropriate and well-supported across all encounters.

Conclusion

Accurate use of Modifier 25 requires careful documentation, precise coding and consistent compliance with payer rules which can be challenging for busy urgent care practices. Outsourcing urgent care billing and coding services to specialized providers such as 24/7 Medical Billing Services ensures that claims are reviewed by experts who stay up to date on evolving CPT, ICD-10 and payer guidelines. These services streamline coding, reduce errors and improve revenue capture by verifying medical necessity, proper modifier application, and distinct E/M evaluation. Therefore partnering with an experienced billing partner not only minimizes denials but also enhances overall operational efficiency and financial performance.

FAQs

Can Modifier 25 be used for multiple procedures on the same day?

No, it applies only to E/M services performed alongside a procedure.

Is Modifier 25 applicable for telehealth visits?

Yes, if a separately identifiable E/M is provided during the telehealth encounter.

Does using Modifier 25 affect patient cost-sharing?

It may, depending on the payer and how the E/M is reimbursed.

Can a nurse practitioner or PA use Modifier 25?

Yes, as long as they are authorized to provide the E/M and procedure.

Can Modifier 25 be used for same-day follow-up visits?

No, it applies only to the initial encounter where the procedure is performed.